=====================================================
General NPI Number Information
=====================================================
NPI Number | 1043835978
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | BROSCO CHIROPRACTIC LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/16/2020
-----------------------------------------------------
Last Update Date | 06/16/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 500 N DEARBORN ST STE 700
-----------------------------------------------------
City | CHICAGO
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60654-3397
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 737-683-2201
-----------------------------------------------------
Fax | 773-260-1612
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1127 W WRIGHTWOOD AVE # 3W
-----------------------------------------------------
City | CHICAGO
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60614-1314
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 401-486-9850
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER/CHIROPRACTOR
-----------------------------------------------------
Name | ARIANA COLETTI
-----------------------------------------------------
Credential | DC
-----------------------------------------------------
Telephone | 401-486-9850
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 111N00000X
-----------------------------------------------------
Taxonomy Name | Chiropractor
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------